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ORIGINAL ARTICLE
Year : 2018  |  Volume : 21  |  Issue : 3  |  Page : 122-127

A 5-year review of measles cases admitted into the emergency paediatric unit of a tertiary hospital in Sokoto, North-Western Nigeria


Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication4-Oct-2018

Correspondence Address:
Dr. Khadijat O Isezuo
Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto
Nigeria
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DOI: 10.4103/smj.smj_38_17

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  Abstract 


Background: Measles is a vaccine preventable viral infection which is still responsible for significantly high morbidity and mortality in Sub-Saharan Africa. Failure of routine immunization programs heralds a dismal outlook for this potentially eradicable viral infection. The objective of this study was to determine the hospital prevalence, vaccination status, pattern of complications, and outcome of children admitted with measles into the Department of Pediatrics of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Materials and Methods: This was a 5-year retrospective study from January 1, 2011 to December 31, 2015. Case folders of children below 15 years who were admitted with measles were retrieved, relevant information extracted, and entered into a pro forma. Data was analyzed using SPSS version 22. Results: Total admissions were 6104, out of which 204 were due to measles (prevalence, 3.3%). The mean age was 27.4 ± 18.9 months (range 6–96 months). Those aged 1–5 years were 144 (70.6%). The male-to-female ratio was 1.3:1. Only 28 patients (13.7%) had measles vaccination. Observed complications included bronchopneumonia in 168 (82.4%), acute laryngotracheobronchitis in 24 (11.8%), febrile convulsion in 20 (9.8%), encephalitis in 17 (8.3%), ocular complications in 12 (5.9%), and suppurative otitis media in 6 (2.9%) patients. The presence of complications was related to age <5 years (P = 0.0001) but not to vaccination status (P = 0.41). Forty-four patients died (21.6%), whereas 33 patients (16.2%) had residual problems at discharge. Outcome was related to vaccination status (P < 0.05). Conclusion: Measles is still a significant problem in the study area and it is associated with high morbidity and mortality. More efforts at prevention is necessary.

Keywords: Admissions, hospital, measles, review, Sokoto


How to cite this article:
Isezuo KO, Yusuf T, Ibitoye PK, Sanni MA, Jiya NM, Sani UM, Ahmad MM, Jibrin B, Waziri UM, Jangebe MA. A 5-year review of measles cases admitted into the emergency paediatric unit of a tertiary hospital in Sokoto, North-Western Nigeria. Sahel Med J 2018;21:122-7

How to cite this URL:
Isezuo KO, Yusuf T, Ibitoye PK, Sanni MA, Jiya NM, Sani UM, Ahmad MM, Jibrin B, Waziri UM, Jangebe MA. A 5-year review of measles cases admitted into the emergency paediatric unit of a tertiary hospital in Sokoto, North-Western Nigeria. Sahel Med J [serial online] 2018 [cited 2018 Nov 19];21:122-7. Available from: http://www.smjonline.org/text.asp?2018/21/3/122/242745




  Introduction Top


Measles is a highly infectious illness caused by an RNA virus.[1] It is highly fatal because it is very contagious and complications from the disease affect every organ system. Pneumonia, croup, and encephalitis are common causes of death, whereas long-term sequelae are still common from encephalitis.[2] Measles is still a common cause of blindness in developing countries. Complication rates and fatality are higher in under-fives in developing countries. This is not surprising giving the association of these complications with malnutrition, vitamin A deficiency, lack of measles vaccination, and intense exposure to measles infection, especially in overcrowded households.[3],[4]

More than 30 million people are affected by the disease each year.[5] Case-fatality rates have decreased in many countries but remain high in developing countries. Globally, it was 8th among the 10 leading specific causes of global disability-adjusted life years (DALYs) in the 90's.[6] In 1980, before widespread vaccination, measles caused about 2.6 million deaths each year. This has reduced significantly following the introduction of measles vaccination, one of the most cost-effective health interventions ever produced.[2] About 17.1 million deaths were averted by measles vaccinations administered between 2000 and 2014.[5] However, measles is still responsible for significantly high morbidity and mortality in Sub-Saharan Africa due to the failure of routine vaccination. This heralds a bleak outlook for an infection that has a potential for eradication.[7]

Globally, measles-related deaths declined rapidly from 544,200 deaths in 2000–114,900 in 2014 but then rose to 134,200 in 2015 which was attributed to stagnation in the overall progress toward increasing global immunization coverage after 2010.[5],[8] Nigeria is not left out of this burden as it was among the 45 countries that accounted for 94% of the global deaths due to measles in 2016.[7]

The brunt of measles as a preventable cause of child mortality should be reassessed, especially in areas with rampant vaccination refusal in Northern Nigeria. Most studies in Nigeria are from tertiary hospitals and show the prevalence of measles to be 1.3%–5.1% among hospitalized children.[9],[10],[11],[12],[13] A study carried out in the same area almost 2 decades ago before the Millennium Development Goals (MDGs) and Measles and Rubella Initiatives were set up showed that vaccination rates were low and mortality was high among admitted cases.[14]

Hence, this review of cases of measles admitted in the past 5 years in the Usmanu Danfodiyo Teaching Hospital (UDUTH), Sokoto, to assess the current trend in hospital prevalence of measles, vaccination status, pattern of complications, and outcome, especially as the MDGs wrapped up in 2015.


  Materials and Methods Top


Study area

The study was carried out at the Emergency Pediatric Unit (EPU) of Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto State, North-western Nigeria. This is a tertiary health facility located in Sokoto, the Sokoto State capital. The hospital serves as a referral center for more than 10 million people of the States of Sokoto, Zamfara, and Kebbi; and the neighboring Niger and Benin Republics in the West African subregion.[15] Sokoto State is located in the dry Sahel region and is surrounded by sandy Savannah. Sokoto town lies between 13°05' North and 05°15' East of the Equator.[16] It has an annual average temperature of 28.3°C, with the highest temperatures reaching up to 45°C during the hot dry months. The rainy season is short and begins late in May till September with a mean annual rainfall of 550 mm.[16] The dry season comprises the hot dry season before the rains from March to April and the cold dry season from November to February.[17] Measles is highly transmitted during the hot, dry season.

Study design

This was a retrospective study conducted over a 5 year period (January 1, 2011–December 31, 2015).

Study subjects

Children aged 15 years and below admitted into the EPU with a diagnosis of measles clinically defined by the Center for Disease Control as: any child with fever and maculopapular rash (i.e., nonvesicular) and cough, coryza (i.e., runny nose), or conjunctivitis (i.e., red eyes).

Excluded were neonates, those diagnosed with prodromal symptoms only without rashes, those with suspected drug reactions as a cause of their rashes. Case folders of children ≤15 years that satisfied that definition criteria were retrieved, relevant information extracted, and entered into a pro forma.

The information retrieved included demographics, clinical features, nutritional status and measles vaccination status, recent history of contact with someone with measles, complications and disease outcome.

Data entry and analysis

The data were analyzed with SPSS Statistics for Windows, Version 22.0 (Armonk, NY, IBM Corp. Released 2013). Quantitative data were expressed as means and standard deviation, whereas categorical variables were expressed as proportions. Chi-square or where necessary, Fisher's Exact test, was used to test for statistical significance. The P < 0.05 was considered statistically significant.

Ethical consideration

The study was approved by the Hospital Ethics Committee.


  Results Top


The total admissions for the period (January 2011 to December 2015) were 6104, out of which 204 were due to measles giving a prevalence of 3.3%. Seventy-five (36.8%) of the measles patients were admitted in 2015 and 4 (2%) in 2014 with the peak occurrence in the hot and dry months of March to April. [Figure 1] shows the cumulative monthly distribution during the study period.
Figure 1: Monthly distribution of the measles cases admitted from January 2011 to December 2015

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There were 116 (56.9%) males and 88 females (43.1%) with M:F = 1.3:1. The mean age was 27.4 ± 18.9 months (range - 6 months to 96 months). Seventy-eight (38.2%) cases were in the age bracket of 12.1–24.0 months, 49 (24%) were aged ≤12.0 months as depicted in [Table 1].
Table 1: Age and gender distribution of the measles cases

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Twenty-eight (13.7%) cases had measles vaccination, 132 (64.7%) patients were not vaccinated, among these were 18 (8.8%) who were <9 months of age which is the NPI age for measles vaccine. The reason for not vaccinating the children was ignorance in 61 (29.9%), religious belief in 21 (10.3%), unavailability of vaccine in 9 (4.4%) of the cases, and no reason was advanced in 23 (11.3%) of the cases. Furthermore, the status of 44 (21.6%) was unknown. Seventy-five (36.8%) had contact with another child with measles.

A total of 184 (90.2%) of the cases developed complications, whereas 20 (9.8%) did not have any complication recorded. The most frequent complications were bronchopneumonia and diarrhea which were seen in 168 (82.4%) and 101 (49.5%) of the children, respectively. Other complications include croup in 24 (11.8%), febrile convulsion in 20 (9.8%), encephalitis (measles related coma) in 17 (8.3%), ocular complications in 12 (5.9%), and suppurative otitis media in 6 (2.9%) of the cases as shown in [Table 2]. All the complications were higher among those aged between 1 and 5 years of age; however, this was only significant for bronchopneumonia and diarrhea. Those <1 year of age also had higher proportion of multiple complications (P = 0.02).
Table 2: The age distribution of the complications of measles

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The pattern of complications according to the vaccination status was also assessed. There was a higher rate of all complications among the unvaccinated. It was found that all those who had ocular complications had not been vaccinated (P = 0.03). The nutritional status (using the Modified Welcome classification) of the children admitted with measles was underweight in 95 (46.6%), 67 (32.8%) were normal, and 17 (8.3%) had marasmus while the nutritional status of 24 (11.8%) was not documented. Those with diarrhea and those with more than 1 complication were more undernourished which was significant. This is shown in [Table 3].
Table 3: The complications of measles according to the nutritional status

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The duration of admission was 5.4 ± 5.5 days (range 1–49 days). Ninety-nine of them (48.5%) spent between 3 days and 1 week on admission while 60 (29.4%) spent <72 hours on admission and 45 (22.1%) spent more than a week on admission. There were 44 deaths giving a mortality rate of 21.6%. Most of the deaths occurred within 72 hours of admission (38/44, 86.4%) and this was statistically significant. The proportionate mortality was higher among the males than females (22.4% vs. 20.5%) but was not significant (P = 0.44). Mortality was also higher among the 1.1–5-year-old category compared to those below 1 year (23.6% vs. 21.3%). There was no mortality among those above 5 years of age (P = 0.14).

It was found that the cases who had not received measles vaccine had a higher mortality rate despite the unknown vaccination status of 21.6% of the cases as shown in [Table 4]. The proportionate mortality was 26.5% versus 18.2% versus 3.6% among the unvaccinated, those with unknown status and the vaccinated patients which was statistically significant (P = 0.014). The nutritional status was also significantly related to the outcome of the patients as those who were underweight and marasmic had higher mortality rate than those with normal weight. This is shown in [Table 5].
Table 4: The outcome of the measles cases in relation to their vaccination status

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Table 5: The nutritional status and mortality of the measles patients

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  Discussion Top


In this study, 204 cases of measles were seen which accounted for 3.3% of the admissions during the 5 year period. This is lower than 4.3% reported by Ibrahim and Jiya from the study area over same duration about 2 decades ago when 201 cases were seen.[14] Hence, there may be no true difference in measles occurrence in the study area as the absolute number of cases seen during the different periods were similar. The prevalence of 3.3% was lower than 14.2% and 8% reported from Kano[10] and Bida,[18] respectively probably because of the shorter study periods. Furthermore, the Kano study was conducted during an intense epidemic period which lasted 3 months so a higher number of cases were seen.

The prevalence from this study of 3.3% was however similar to reports from Benin (3.1%) but higher than figures of 2% from Yenagoa[11] and 1.6% from National Hospital, Abuja.[9] In Uganda, measles constituted 2.0% to 4.2% of admissions in different districts of the Kampala.[19] Measles occurs in outbreaks in different locales at different periods which may also be responsible for some of the wide variations seen nationwide. However, these figures also depend on the total number of admissions, length of the study period and health-seeking behavior of the populace, and availability of other health facilities in the area.[9] All these studies shows that measles is a burden nationwide. Most cases were also seen in the hottest months of March to April as reported by others.[10],[11],[12],[13],[18]

There was a male preponderance which is also what has been reported by most previous studies.[9],[10],[14],[18] Regarding the age distribution, majority were aged 13–24 months which is similar to what was reported by previous studies from Sokoto,[14] Benin,[13] Bida,[18] Osogbo,[20] Abuja,[9] and Kano.[10] This age predilection is supported by the fact that measles antibodies acquired from infection with the virus have been found to rise significantly from the age of 12 months in population studies.[21],[22] This is because of increased vulnerability to infection from that age as maternally derived placental antibodies would have waned. Studies have also shown that early waning of these maternal antibodies is common in developing countries leading to increase rates of measles outbreaks in infant including those below 9 months of age who are not due for the vaccination.[23],[24] A supportive fact for this was the finding in a study by Loening and Coovadia that there was a positive association between increasing population density and the percentage of measles cases aged 8 months or less.[23] In the index study, 8.8% of the patients were below the age of 9 months and were not due for vaccination. This was lower however than the 23.1%, 20.4%, 18.1%, 16.5%, and 14% of infants below 9 months affected with measles as reported from Yenagoa,[11] Ibadan,[25] Benin,[13] Sagamu,[12] and Maiduguri.[26] Most of these cities have higher population density than Sokoto, and this supports the foregoing finding by Loening and Coovadia.[23],[27]

This persistence of measles infection which is highly vaccine preventable in this study area and the country at large is not surprising giving the low rates of vaccination coverage reported. In this study, only 13.7% of the admitted cases had measles vaccine, which was even much lower than the 23.1% vaccination rate reported 17 years earlier in the study area by Ibrahim and Jiya.[14] This vaccination rate is also the lowest compared to other areas in the country which range from 18.5% to 53.5% among measles cases that were admitted.[10],[11],[12],[13],[18] However, all being hospital based studies in metropolitan areas, this rates may not reflect what obtains in the community.

The rates of the two leading complications of bronchopneumonia and diarrhea disease were higher than what has been reported in the previous studies.[9],[11],[12],[13],[14],[20],[26] Pneumonia is the most common and severe complication, with varying causative agents including the measles virus itself and other secondary viral and bacterial agents.[28] It is not surprising that it is responsible for most measles associated deaths.[28] Although, those aged 1–5 years had higher rates of the individual complications, infants in this study had higher rate of multiple complications which probably reflects their lower level of immunity based on their vaccination status and decline of maternal-derived antibodies (early seroconversion).[11],[28],[29] Okada et al. found that infants had prolonged lymphopenia after measles infection with slower resolution of symptoms.[30] Ashir et al. also found that infants had prolonged hospital stay compared to the older group among their patients though this was not assessed in this study.[26] There have been calls for lowering the age for measles vaccine administration because of increasing rate of measles seen in infants below 9 months.

The unvaccinated and those who were malnourished had a higher rate of complications which is also similar to the previous reports.[9],[11],[12],[13],[14],[20],[26] It was also found that mortality was significantly associated with lack of measles vaccination and malnutrition. Case fatality rate was 21.6% which is higher than other recent reports, ranging from 3.9% to 19%. It is also higher than the 12.4% previously reported from the center by Ibrahim and Jiya.[14] This is probably reflects the low vaccination rates seen in this study and the higher rate (82.4%) of mortality prone complication (bronchopneumonia) seen among these patients compared to other studies.


  Conclusion Top


Measles infection still contributes to significant morbidity and mortality in the study area. It occurred predominantly in the 2nd year of life. Lack of vaccination and malnutrition were associated with mortality. It is therefore recommended that efforts should be geared toward tackling these with evidence-based information for the populace and government to increase vaccination against measles. There should also be more attention paid to the management of measles patients with malnutrition and those who are not vaccinated to reduce attendant mortality, particularly within the immediate admission period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Olaitan AE, Ella EE, Ameh JB. Comparative seroprevalence of measles virus immunoglobulin M antibodies in children aged 0–8 months and a control population aged 9–23 months presenting with measles-like symptoms in selected hospitals in Kaduna State. Int J Gen Med 2015;8:101-8.  Back to cited text no. 22
    
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30.
Okada H, Kobune F, Sato TA, Kohama T, Takeuchi Y, Abe T, et al. Extensive lymphopenia due to apoptosis of uninfected lymphocytes in acute measles patients. Arch Virol 2000;145:905-20.  Back to cited text no. 30
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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